I found myself ranting at Twitter earlier today about the quality of transfer letters that I’ve been getting lately. I try not to moan about things that are being done largely by new F1s, because I was one not very long ago and really very few of the skills that are needed in F1 are things that are either learned in medical school or picked up on instinct. The art of writing a good transfer letter – like the art of making a good referral and getting through a weekend jobs list without your head exploding – is a teachable skill that people don’t bother to teach. I’m choosing to assume that people aren’t writing appalling letters on purpose, they’re doing it because they have no idea how.
So, this is partly educational and partly a self-serving exercise in trying to raise the bar high enough that I can stop giving myself a concussion with all the *headdesk* that I’ve been doing.
This is not a lesson according to the textbooks, nor is it a lesson that I necessarily expect everyone to agree with. This is a lesson in how to write transfer letters as given by someone who wrote a lot of them last year and now spends a lot of time reading them. Your mileage may vary. Comments welcome. Etcetera.
The first thing to know is that, yes, if you have a patient who is going to another hospital, you do need to write one. Forgive me if that sounds unbearably patronising. But the winner in the league of terrible transfer letters goes to the person who sent someone to my ward in the middle of the night with no letter, no old notes, and no drug chart.
The second thing to know is that this is the medical handover. A patient’s care is being transferred from one doctor to another in a very direct and more emergent way than it is in your average discharge letter, and for that reason this is a time when I’d rather sift through too much information than not have enough. My rule of thumb when I’m writing one is that the receiving doctor should be able to do most of their clerk in from what I’ve written.
Now, let’s take it part by part.
1. Why are you transferring them? Or if it’s because you’re now transferring them back, why were they sent to you in the first place?
Thank you for agreeing to take over the care of Mr Smith, who requires further evaluation and management of his recently diagnosed pancreatic cancer.
Thank you for accepting back the care of Mr Smith, who was transferred to Balamory Hospital on 16/03/12 for inpatient angioplasty following NSTEMI.
2. I’m going to need catching up on the story that brought them into hospital in the first place. The simplest way to do this is to turn to their original history of presenting complaint, read it, and summarise it.
Mr Smith is a 78 year old gentleman with a 20-pack year smoking history who initially presented with a 6/52 history of increasing shortness of breath on exertion and recurrent chest infections. He had been treated with several courses of oral antibiotics to little effect. He reported a two stone weight loss over the previous 4/12, but was otherwise systemically well.
3. A quick line on the important past medical history.
PMH includes rheumatoid arthritis, T2DM (insulin-controlled), and hypertension.
4. I’m now going to need catching up on what has happened since they arrived in hospital. This will include what treatment has been given, any investigations and their results (which in the case of blood results includes numbers and in the case of scans includes a full report, especially if the patient is being transferred outside of their current Trust), and how the patient is at the moment.
At admission, LFTs were grossly deranged (Bilirubin 64, AST 132, ALT 210). Abdo USS showed a thickened oedematous gallbladder and CBD dilatation at 15mm. He remains on IV amoxicillin, gentamicin, and metronidazole for treatment of biliary sepsis. He is clinically much improved, and is apyrexial with resolving inflammatory markers (CRP 51, WCC 11.2). Bloods are otherwise unremarkable. He has had an MRCP, and the formal report is enclosed.
5. Are there any outstanding results?
A Hepatitis C test was sent on 09/12/13. The results of this are awaited.
6. If your patient has, for example, metastatic cancer, please tell me whether they know that they have metastatic cancer.
He is aware of his diagnosis, but has not yet been told the results of his staging CT.
7. What am I meant to be doing?
He is being transferred to you for emergency radiotherapy.
He requires a further period of rehabilitation before arrangements are made for discharge home.
8. What do I need to know about their home circumstances? If they’re coming to a surgical ward for an ERCP and then going straight back to the medics, not much. If they’re going to a community hospital for discharge planning, a lot.
Mr Smith lives at home with his partner, and has good support from his daughter and son-in-law. He has previously been independent of ADLs and does not have a package of care. He is usually independently mobile with one stick, but while on the ward has been requiring a Zimmer.
9. I will need a list of their current medications. Not “as per Kardex”. Sometimes the Kardex doesn’t come or it gets photocopied with a missing page or bits of it are completely illegible.
His current medications are:
10. Who are you and how can I get in touch with you?
If you have any further questions, please do not hesitate to contact me.
Dr Beth Routledge
FY2 in General Medicine